NUR 324 Nursing Process & Clinical Judgment Model Flashcards
The nurse is conducting an interview of a patient admission. Which data should the nurse document as subjective? A. Nausea B. Light-headedness C. 100.1 degree temperature D. 120/80 BP E. Red rash F. Discomfort in the stomach
A, B, F
Which statement describes a characteristic of clinical judgment in nursing practice?
A. It is simple and easy to apply.
B. It is the foundation of safe, competent practice.
C. It provides standardization of treatment options.
D. It slows decision making to consider all factors.
B
Name some nursing interventions.
Monitoring, teaching, education
Nursing interventions: Independent vs. Dependent
Independent: assessment, monitor, and teaching –> VS, IO, height, weight
Dependent: requires the HCP –> labs, meds, treatments needed
Do you need an order for PT? Chaplain?
yes, no
KNOW: Nursing interventions are specific and need a time frame. SMART interventions.
Ex. teach about IS use, encourage use q 1 hour x 15
Nursing Process: A.D.P.I.E.
A: Assessment D: Diagnosis P: Planning I: Implementation E: Evaluation
Nursing Process: ASSESSMENT
- Gather information about the patient’s condition
- Picking up on cues that something is wrong with our patient
Examples: MAR, H&P, LABS, Diagnostic Tests
Nursing Process: DIAGNOSIS
- ID the patient’s problems
- Do not use medical problem –>
- ——————-pneumonia NO
- ——————-weak cough, infection, poor lung sounds, fever YES
Example: Pain, respiratory function, managing xyz
Nursing Process: PLANNING
- Set goals of care and desired outcomes
- SMART goals and outcomes: clear interventions, pt. centered
Ex. “Keep pt. pain level at a level 4 during the entirety of my shift.”
Intervention – “What will I do? Give pain med/tramadol”
Nursing Process: IMPLEMENT
- Perform the nursing actions identified in planning
- Be specific: q6h, pain assessed q2h
Ex. Assess, monitor, implement, collab, teach, psychosocial
Nursing Process: EVALUATE
- Determine if goals & expected outcomes are achieved
- Did it work? If not, how did we address this?
Clinical Judgment Model
Recognize cues –> analyze cues –> prioritize hypothesis –> generate solutions –> take action –> evaluate outcomes
CJM: RECOGNIZE CUES
- ID relevant clinical data, observe, assess
- Report, MAR, Labs
CJM: ANALYZE CUES
Be able to interpret cues, organize & recognize patterns in order to link the pt.’s clinical presentation to a problem
- Clustering cues: SOB and Tachycardia go together
CJM: PRIORITIZE HYPOTHESIS
Narrow problems down to the most pressing problem
What problem is the priority? Remember ABCs are top priority.
CJM: GENERATE SOLUTIONS
Determine desired outcomes and the best solutions.
Determine what resources you may need.
Do you need to collab? Meds?
CJM: TAKE ACTION
Implement nursing interventions based on your plan
CJM: EVALUATE OUTCOMES
Compare observed outcomes to the desired/expected outcomes.
Did they work?
What part of the CJM matches with ADPIE?
A - recognize cues D - analyze cues P - prioritize hypothesis, generate solutions I - take action E - evaluate outcomes
After 0800 assessment, the nurse determined the patient is at risk for fluid imbalance.
What part of the nursing process did the nurse determine this in?
What step of the CJM is she in?
Diagnosis
Analyze cues
What does SBAR stand for?
S - Situation
B - Background
A - Assessment
R - Recommendation
SBAR: Situation
- Symptom/reason why you are calling HCP
“Hello HCP, this is Mary, Nursing Student, from 5 North. I am calling you about J.B. in room 531. As you might recall, he was admitted 2 days ago for a total knee replacement. I am calling you now because I am concerned that he is complaining of sudden SOA and severe chest pain while lying in bed.” “
SBAR: Background
- Includes critical cues you gather to “persuade” the HCP is worth dialoguing about. Only include relevant info. Assessment goes here.
“Also, Mr. Brown’s lips are cyanotic (this is new) and his current O2 sats is 88% on RA where it has been 93%. His HR has also become tachy in the 110s and his RR is labored with a rate of 24 bpm. He was in normal sinus rhythm with no cardiac history that I am aware of at the time of admission.”
SBAR: Assessment
- What you think is going on. May give diagnosis or be uncertain.
“I am concerned/I think that Mr. Brown may have/has a pulmonary embolus.”
SBAR: Recommendation
- What you want done.
- “I think the following needs to be done… meds, labs, tests, assess pt…”
- Include timeframe in discussion
- Be sure that by the end of the call, it is specific and you know what is happening with you and the HCP.
“I’d like to start Mr. Brown on supplemental oxygen by face mask. Do you agree? Also, would you like me to order a immediate chest x-ray or CT scan?”
